Care of Wound Reconstruction Patients, 2018 ed.

Transcription

1 Care of Wound Reconstruction Patients, 2018 ed. STEVE GROSSO, MD, FACS BILLINGS PLASTIC SURGERY A Smorgasbord of Plastic Surgery Stuff Disclaimer/Conflicts of Interest It is not possible to discuss wound care without discussing products by their name. I am not a consultant for any of the company product I will discuss. I do not receive any royalties or fees from any company I will name. I do not own any significant interest in any wound care company. If you feel there is a bias in discussing one product over another, it is due solely to my experience with the product, my preference, product performance, and/or market availability. Nobody is giving me $ for my product discussion, or for presenting, unless somebody hands me an envelope of small unmarked bills ($10 s and $20 s, preferably) at the end of my talk 1

2 Who ya gonna call? Wound Care will depend on the type of closure performed Dressing changes Wet to dry gauze/saline Alginate products, collagen, etc Wound Vac Wound healing promoters Epifix Apligraf Dermagraft Cytal/Micromatrix Skin substitute Integra PriMatrix Wound Care will depend on the type of closure performed Skin graft Skin flap Muscle flap with skin graft Fasciocutaneous flap Myocutaneous flap Free flap 2

3 Open knee wound Options for treatment: Amputation Dressing changes VAC Skin substitute Skin graft Skin Flap Wound Vac Typical therapy is -125mm Hg continuous suction Reasons to consider other settings: Pain Drainage What is in the bed of the wound (tendon/bone/ vessels/nerves) Options include: Higher/lower suction (vacuum) therapy Intermittent therapy White vs black sponge Intermediate layer Wound VAC White Foam Black Foam Less porous Less sticky to tissues Less suction More porous More suction possible Consider intermediate layer (adaptic/mepitel) 3

4 v.a.c. ulta And there s more v.a.c. veraflo therapy VAC Veraflo Therapy Instillation of fluids Dwell time Negative Pressure Therapy Prevena Intermediate Layers Mepitel One Track the sponge 4

5 Classic Wound Healing Tissue Disruption Coagulation Immune Response Angiogenesis Collagen Deposition Scar Tissue The Extracellular Matrix (ECM) Complex 3-D network of biological molecules Define physical and geometric properties of a tissue Substrate that serves as a site for cell attachment, migration, proliferation, and differentiation Constructive Remodeling Tissue Disruption Coagulation Immune Response Angiogenesis Collagen Deposition Site Appropriate Tissue 5

6 Differentiating ECM Scaffolds AlloMax Human Dermis AlloDerm Human Dermis Avaulta Plus Porcine Dermis* CollaMend Porcine Dermis* Flex HD Human Dermis InteXen LP Porcine Dermis MatriStem Porcine UBM PelviSoft Porcine Dermis* Strattice Firm Porcine Dermis Strattice Pliable Porcine Dermis Surgisis Porcine SIS SurgiMend Fetal Bovine Dermis Veritas Bovine Pericardium * Chemically Crosslinked Xenform Fetal Bovine Dermis Brown et al., Acta Biomater 2012 Pre-clinical data may not reflect clinical results Ankle Ulcer Integra 6

7 Integra Integra Secured with sutures or staples Stabilized with bolster/dressing/vac/walking boot/etc Stabilizer removed at 1 week and discontinued (boster) or continued (VAC) I prefer to keep the product dry Getting it wet may result in water/bacteria getting under the silicone Use a shower bag if feasible Wait for the color to change to peach suggesting vascularity Remove silicone layer and do skin graft Stabilize the skin graft for a week, then remove stabilizer Do routine skin graft care (topicals/light dressing/protection) Integra Problems? 7

8 PriMatrix Acellular dermal matrix derived from fetal bovine dermis Rich in Type III collagen, a collagen that is active in developing and healing tissues PriMatrix Ag Antimicrobial dermal repair scaffold contains ionic silver, which is intended to prevent microbial colonization of the device Can be used to develop a new tissue layer Graft it later Don t graft it later? PriMatrix PriMatrix 2 layer, no bolster. Treated with ointment. Top layer fell off. Continue treating with antibacterial ointment or Vaseline. Keep it moist. 8

9 PriMatrix 2 layer, bolster Cytal = Urinary Bladder Matrix (UBM) Cytal/Micromatrix Cytal products contain the epithelial basement membrane from porcine urinary bladder, and are based on the proprietary ECM composition generally referred to in scientific literature as urinary bladder matrix, or UBM. UBM is a segment of tissue layers that facilitates a constructive tissue remodeling response by the patient s body Wound matrix: single layer, 2 layer, 3 layer, 6 layer; Burn matrix 2 layer These devices are intended for the management of partial- and fullthickness wounds including pressure ulcers, venous ulcers, diabetic ulcers, tunneled wounds, traumatic wounds, and surgical wounds ACell s wound management portfolio also includes MicroMatrix, MatriStem Wound Matrix, MatriStem Multilayer Wound Matrix, and MatriStem Burn Matrix 9

10 Sheets, fenestrated, powders Acell Open Abdominal Wound Goal: Granulated bed which will accept a skin graft. Secondary abdominal wall reconstruction. 10

11 wait for it.. Preop 2 mo. after Skin Graft/Micromatrix 2 mo. after Burn Matrix 4 mo. after Burn Matrix Keep it moist. But not too moist. Just right. Antibacterial ointment? KY Jelly? Telfa? ABD pad? Necrosis of skin flap What do you do with this? 42 y/o female with melanoma on leg Wide local excision, intraoperative consult for closure Multiple skin flap advancements Flap necrosis, debrided at bedside Open wound Sensitive/painful Patient doesn t want to go back to OR 11

12 Non-surgical options Skin and wound became too sensitive to use VAC Needs debridement Switched to wet to dry dressings with gauze/saline. Got too fibrinous in base, couldn t do bedside excisional debridment Switched to gauze/santyl (collagenase). Santyl/gauze result Want a skin graft? No. 12

13 and most recently Hydrogel/Optifoam Fornier s Gangrene Scrotal Excision Perineal Reconstruction Testicles Are Buried in SQ plane No Scrotal Reconstruction Skin Flap Advancements Split Thickness Skin Grafts Aftercare?... Protection: Activity - Progressive Suture Duration 7 vs 14 vs 28 days Cleaning: Shower/Soap/Water 13

14 Metastatic Breast Cancer Chest wall (not breast) reconstruction with Skin Flap (skin/subcutaneous) Aftercare for skin flap Protection Different for different body parts (nasal skin flap vs chest wall) Limit Range of Motion Limit weight bearing/pressure points Suture removal at 2-4 weeks (anatomical decision) Cleaning Dressing change may/may not be needed OK to shower Possibly antibacterial ointment for a brief time Soft Tissue Injury and Repair 14

15 Soft tissue injury repair Topical Antibacterial Ointment Skin care creams Mederma, Silicone, Vitamin E, Bag Balm, you name it This is your ankle on meth Pedestrian vs automobile Medial malleolus ground down Significant soft tissue loss Fasciocutaneous Flap 15

16 and Split Thickness Skin Graft Skin graft donor site = thigh Skin Graft Donor Site Dressings Mepilex Border Mepilex Transfer Biobrane Xeroform Wound Vac Silver alginate You name it The key is to allow the skin to heal Coverage in the meantime is temporary The skin will regenerate from the hair follicles and sweat glands in the skin The product, scab, or other surface attachments in the meantime should protect the skin and give some relief Split thickness skin graft donor sites are painful Shower/blow it dry/pat it dry vs waterproof dressings Split/Full Thickness Skin Graft Care Stabilizer for +/- 1 week Wound vac Bolster (eg, xeroform/cotton ball) Remove stabilizer Evaluate skin graft Ongoing wound care Wound vac Dressing changes Xeroform Bacitracin/Telfa/Tape/Kerlix/Ace End point of wound care is a re-epithelialized skin surface Moisturizing lotion/sunscreen 16

17 Free Tissue Transfer Rectus to foot 9/30 10/12 11/1 11/22 - Don t be afraid of it. - Clean the slime. - Remove devitalized tissues - Keep it moist if it is trying to re-epithelialize - Protect the tissue - Treat the sequelae of healed tissue/scar 12/28 3/29 Extremity Flap protection Weight bearing vs non-weight bearing Crutches Walker Immobilization Splint Walking boot Control of edema Elevation Compression stockings Skin care Shower daily Soap and Water +/- Antibacterial ointment on suture line Skin lotions Think, how can this flap get hurt? Think, how can I help the healing? Necrotic Sacrococcygeal Pressure Sore and then some 17

18 with gluteal muscle necrosis and acetabular bone abscess Gluteal Muscle Excision Acetabular Bone Excision Closure of remaining Gluteal Muscles over a drain VAC sponge in the Sacrococcygeal Defect Delayed Reconstruction with Myocutaneous flap? Aftercare: Protective positioning (off pressure sore/buttocks), air/sand bed, VAC sponge changes Pressure Sore Reconstruction Problems that lead to pressure sores (and other wounds) Malnutrition Paraplegia/lack of sensation Infection/Osteomyelitis Smoking/nicotine Non-compliance 18

19 Myocutaneous Flap Aftercare Protection No pressure. Bed rest. Do not sit on flap OK to be prone, lateral on right or left side, supine Bed of Nails Theory if Supine HOB 20 degrees or less except for meals OK 30 degrees or less for 30 minutes or less Drain care Protective mattress 3 to 6 to 8 to 12 weeks Sitting Protocol Advancement Nutrition, Antibiotics, Hygeine Sitting Protocol Increase daily sitting over the course of 7-10 days 30 min x 3 45 min x 3 60 min x 3 90 min x min x min x 3 Check pressure points after each sit Hoyer lifts into chair Pressure mapping at some point Equipment update 19

20 Melanoma Excision Defect Forehead Flap Reconstruction Xeroform or Ointment/Telfa pad to forehead Nasal Reconstruction 20

21 Preparation for Division/Inset Flap care: soap/water/+/- ointment After division/inset No wound care needed Cartilage Graft from Ear to Nose With Nasal Skin Nip and Tuck 21

22 Wound care: skin cleaning, ointment. No expensive products. Questions? 22